Thousands of patients are feared to be dying needlessly every year because of poor communication between hospital staff, faulty equipment and a lack of skills.

An analysis of errors has found that some staff failed to make basic checks and that others did not see that their patient’s condition was quickly deteriorating, with fatal results.

The National Patient Safety Agency study, which investigated the circumstances in a sample of deaths, also found that there were problems with resuscitating some of the patients.

Publication of the study’s findings coincides with new guidelines from the National Institute for Health and Clinical Excellence on how health workers should manage sudden declines in patients’ health.

Every year about 13 million people are admitted to acute hospitals in England and Wales. Estimates of the number of deaths due to medical errors vary between 800 and 34,000 a year, but the true scale is unknown because NHS staff are often reluctant to report mistakes and close calls.

The agency said that 1,804 serious incidents were reported as resulting in death in 2005, with 576 of these cases being avoidable. Of those, the study selected 107 deaths for investigation – 64 in which a patient’s deterioration was not recognised or acted upon and 43 that involved problems with resuscitating a patient after cardiac arrest.

The remaining deaths outside the study included 71 related to diagnostic errors, and others due to medication error, suicide and stillbirth after complications. The agency’s snapshot analysis found that, where a patient had quickly deteriorated, there were 14 cases in which no observations had been made for a “prolonged period prior to death and changes in vital signs were not detected”. In 30 cases, despite the recording of vital signs, there had been no recognition of deterioration and/or no action taken. In another 17 cases, there had been a delay in providing medical attention.

Among the 43 deaths involving resuscitation, the study found that many suggested that “medical and nursing staff did not have the depth of knowledge and skills required. In most cases the delay in starting resuscitation was reported to be because staff did not recognise the acute situation, failed to call the resuscitation team or did not attempt themselves to resuscitate the patient.”

Fourteen reported incidents related to the use of equipment. In eight cases, equipment such as electrodes, defibrillator leads and paddle, suction devices and drugs had not been available.

One report of an incident said: “During a cardiac arrest, defibrillator found not to have the correct leads and paddle to fit the defibrillator. This caused a delay of approx five minutes during the arrest.”

Last year the Medicines and Healthcare products Regulatory Agency received 141 reports of adverse incidents involving defibrillators. In the first six months of this year, it received 86 reports.

For suction equipment, there were 36 adverse incidents last year, with 16 in the first half of this year.

The reports described may represent only a very small proportion of incidents that occurred, the study said. It set out a series of recommendations, including improvements in communication, training, and the provision of appropriate equipment.

Richard Thomson, the agency’s director of epidemiology and research, said: “Every preventable death is a tragedy, not only for the family but for the staff involved. This report recommends actions that can improve the quality of care of acutely ill patients.”

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